The patient’s symptom of diplopia can be attributed to the palsy of the right superior oblique muscle.
Base out prisms (used to induce convergence) failed to evoke pupillary constriction.
#Argyll robertson pupil youtube full
This was tested several times with full patient cooperation. The pupillary response of the near reflex was absent ( Figure 2B). Pupils were 3 mm, equal, and reactive to light ( Figure 2A). Slit-lamp examination and fundoscopy were normal with no involvement of optic nerves. Visual fields, color vision and optokinetic nystagmus were normal. Patient had hypertropia of the right eye ( Figure 1B), maximal on left gaze with Beilschowsky test positive confirming right superior oblique palsy. There was 6 diopters of accommodation by objective retinoscopy. On examination visual acuity was 20/20 in both eyes at near. Despite improvement in the hydrocephalus, ten days after the shunting procedure the patient developed diplopia for which the ophthalmology service was consulted. Based on elevated opening pressure and the presence of hydrocephalus on neuro-imaging, the patient underwent ventricular-peritoneal shunting. Subsequent bone marrow biopsy and HIV testing were also negative. The CSF tested negative for cryptococcal antigen and Venereal Disease Research Laboratory (VDRL) test, with no growth on bacterial and fungal cultures. Cerebrospinal fluid (CSF) analysis revealed normal protein and glucose levels with 220 WBC’s per high-powered field, which exhibited malignant morphologic characteristics.
Spinal tap revealed an opening pressure of 41 cm H 2O. The studies demonstrated noncommunicating hydrocephalus without focal deficits or infiltrates. Size of the pupil 3 mm.Ĭomputed tomography (CT) scans with and without contrast and magnetic resonance imaging (MRI) of the head was obtained secondary to the presence of headache in order to evaluate for central nervous system involvement. ( B): Primary gaze: Showing right eye hypertropia. ( A): Lymph node biopsy: Showing the typical ‘Starry sky appearance’ seen in Burkitt’s lymphoma.
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